Rooksdown Hospital Plastic and Oral Surgery Centre, Basingstoke

Transcription

1 A CASE OF ARTHROPLASTY OF THE FIRST METATARSAL PHALANGEAL JOINT USING POLYTHENE FILM By CHARLES R. MCCASH, Ch.M., F.R.C.S.E., and K. C. CONDON, M.Ch., F.R.C.S.E. Rooksdown Hospital Plastic and Oral Surgery Centre, Basingstoke A young woman aged 19 years was travelling as a passenger in a motor car when the brakes failed to act. She opened the door and attempted to jump clear, but all she succeeded in doing was to get her left leg out so that the foot was dragged along the ground. FIG. I Original injury. She was admitted to Rooksdown House Plastic Surgery Hospital one hour later with a severe avulsion injury to the dorsum of the left foot. In addition to a full-thickness skin loss, the tibialis anticus and extensor hallucis longus tendons had been divided. Half of the dorsal surface of the first metatarsal bone was missing, and the first metatarso-phalangeal and the tarso-metatarsal joints were open and full of dirt (Fig. i). An emergency operation was performed by Mr Condon, which consisted of a thorough d6bridement and the removal of the multiple foreign bodies from the open joints. The remains of both damaged tendons had to be excised. In spite of the gross contamination it was possible, after cleansing, to cover the surface with split-skin grafts (Fig. 2). At the end of sixteen days the skin grafts had taken well, but it was apparent 71

2 7 2 BRITISH JOURNAL OF PLASTIC SURGERY that a full-thickness skin flap repair would be required. An abdominal tube pedicle was therefore raised for transfer via the wrist to the foot. This procedure was carried out in stages with intervals at home, and eleven months after her accident all scar tissue had been removed and completely replaced by good skin. The damage to the first metatarso-phalangeal joint, however, had produced a bony ankylosis at I8O degrees. Although the patient could stand comfortably she had difficulty in walking owing to the hallux rigidus, nor could she wear a heel on her shoe. She had no pain or swelling of the foot but pointed out that she would not be able to dance or have any choice in the sort of shoes she would like to wear, obviously a serious handicap to a young woman. FIG, 2 After primary skin graft. It was decided to attempt to restore the joint using polythene sheeting which one of the writers (McCash) had been using experimentally with good results in the prevention of adhesions in hand injuries. Operation (25th February I958).--The ankylosed joint was exposed through an incision along the medial side of the skin flap repair. The bony ankylosis was cut through with a chisel in such a manner as to conform with the normal curvature of the joint surfaces. A sheet of gauge 5oo Vis-Queen medium-thickness polythene film was then folded on itself and inserted between the joint surfaces. In order to fix it in position, nylon sutures were passed through the folded corners of the sheet without knotting and both ends brought out on a straight needle through the skin, as shown in Fig. 3, b. When these sutures were drawn tight they pulled the two corners of the film proximally so that it completely covered the lateral aspect of the metatarsal head. The sutures were then tied over pads of gauze. On the

3 ARTHROPLASTY OF THE FIRST METATARSAL PHALANGEAL JOINT 73 el. FIG. 3 Operative technique. FIG. 4 Before arthroplasty.

4 74 BRITISH JOURNAL OF PLASTIC SURGERY medial side of the head the other corners of the film were drawn together with a nylon suture which was tied and buried. This completed the covering of the metatarsal head with a double layer of polythene (Fig. 3, c). The wound was then closed in two layers without drainage. Healing took place normally under antibiotic cover and the sutures were removed on the twelfth day. Apart from some pain during the first night there was no untoward reaction, and the patient was allowed up on the fourteenth day wearing a crepe bandage. A week later she went home walking normally, but with a metatarsal bar to protect the new joint from direct pressure (see Figs. 4 and 5). FIG. 5 After arthroplasty. Five weeks after her operation she was able to stand " on her toes " with ease, the metatarsal bar was removed, and she was allowed to wear ordinary shoes with heels again. When reviewed eighteen months after the operation the patient was walking normally on a shoe with a 2 in. heel. There was no swelling of the joint, which showed a full range of passive movement, and she had 2o degrees' active plantar flexion and a few degrees of active dorsiflexion due, no doubt, to the action of the extensor hallucis brevis (Fig. 6). There was no shortening of the toe. The polythene film in the joint has not been removed, though this could easily be done, if necessary, through a small incision. SUMMARY I. A method of arthroplasty by the use of polythene film to separate the joint surfaces has been described. 2. In the case recorded a satisfactory range of active and passive movement has been achieved and maintained over a period of seven months.

5 ARTHROPLASTY OF THE FIRST METATARSAL FHALANGEAL JOINT The great toe is normal in length and appearance as no bone had to be removed at the operation. 4- The absence of tissue reaction to the polythene film is an important feature in its use, and this point has been borne out in other experimental work by McCash FIG. 6 End result. on tendons and joints in the hand. In other cases where polythene film had been buried in the body and subsequently removed, its texture has remained unchanged. It therefore appears to be an ideal gliding medium to prevent the formation of adhesions and might be employed with advantage in larger joints. Our thanks are due to Messrs British Vis-Queen for the generous supply of polythene film used in this and other cases, also to Miss J. Archer for the drawing, and to Mr E. Ferrill for the photographs.

6 CLOSURE OF FULL-THICKNESS CHEEK LOSS BY FOREHEAD FLAP By RANDELL CHAMPION, M.B.E., F.R.C.S. Christie Hospital and Holt Radium Institute, Manchester SINCE the end of the last century plastic surgeons have been attempting to find the most effective method to repair full-thickness cheek losses. The earliest records show that Israel (1887) used a neck flap folded on itself, involving a three-stage operation. In 1921 Blair described two techniques ; in the first method anterior and posterior neck flaps were used, the one for the skin covering and the other for the lining. Later, he described a case where the lining was obtained by tube pedicle from the neck, and the skin covering from a temporal artery forehead flap. Gillies (I92O, I957) described many ingenious methods for dealing with this type of defect, favouring the use of local flaps and tube pedicles. He also advocated the use of skin-grafted neck flaps to fill such defects. During the war a large number of cases were seen requiring full-thickness cheek replacement, but nowadays only an occasional such case is caused by trauma. The majority of cases requiring full-thickness cheek replacement are due to neoplastic processes. These cases are mainly in the older age groups, and present a rather different problem from those which occurred during the war years. In this older age group it is important to minimise the stay of the patient in hospital and to limit the number of operations the patient has to undergo. It should therefore be the aim of the surgeon to close the wound in one stage, thus avoiding any temporary defect in the cheek through which saliva may be lost, and which, over a long period, causes considerable debility particularly in the elderly patient. Bearing these requirements in mind, the writer has devised the following technique for a one-stage operation, the repair of the defect being carried out at the same time as the neoplastic lesion is excised. In cases where the corner of the mouth has been removed it is restored by Gillies' fan flap. The resulting defect requires a lining and skin covering. A large forehead flap is now designed to fill this defect, and it has been the practice to extend the designing of the flap to up to 5 cm. beyond the midline. The flap is based on the temporal artery, and is mobilised by extending the incisions to the region of the external auditory meatus. It is possible to reduce the width of the pedicle of the flap to about 2 cm. The flap is now fitted into the defect, the terminal 5 to 8 cm. of the flap being turned in to form the new cheek lining. The edges of the turned-in part of the flap are sutured to the mucous membrane of the cheek. By this method 25 to 64 sq. cm. of lining may be obtained. A very thin layer of epithelium is now removed from the skin of the flap, where it turns upon itself to form the lining. The area of this de-epithelialisation is about I cm. in width, and extends across the breadth of the flap. It is very similar to taking a thin split-skin graft from normal skin. This has been described by Gillies. This raised surface is sutured to the raw anterior cut surface of the defect. The remaining portion of the forehead flap is then sutured to the adjacent parts of the skin of the cheek, thus restoring the normal skin covering of the cheek (Fig. I). After the forehead flap has been raised there is often a small bridge of skin remaining posterior to the cheek defect, between it and the donor site of the forehead flap. This small bridge of skin may 76

7 CLOSURE OF FULL-THICKNESS CHEEK LOSS BY FOREHEAD FLAP 77 be removed so as to allow the forehead flap to lie in continuity with the underlying raw surface. This manoeuvre has often reduced further operative adjustment of the flap. The donor site on the forehead is covered with a split-skin graft. The patient is fed with a Ryle's tube for approximately one week post-operatively. Three to four weeks after the main operation further adjustments may be carried FIG. I FIG. 2 Full-thickness cheek reconstruction with folded forehead flap and fan flap, following trauma. out under local anmsthesia. In some cases the excess forehead tissue in the region of the cheek requires excision. In others the forehead flap is divided and the remaining portion replaced on the forehead, after excision of the previously grafted area. Where a fan flap has been performed, widening of the mouth can be carried out at the same time. The writer has completed twelve cases using this technique. Eleven of these cases were following excision of a neoplasm and one only was the result of trauma. The results of these cases (Figs. 2 and 3) compare very favourably with those done by the older, more established, techniques of four to six stages where a chest

8 7 8 BRITISH JOURNAL OF PLASTIC SURGERY wall tube pedicle was used by itself as lining and skin covering, or in conjunction with a forehead flap as skin covering. The obvious advantage of this method is that it entails one major operation and anmsthetic, any further minor adjustments being carried out under local anmsthesia. The amount of time the patient spends in hospital is thus reduced to a minimum. The patient is mobilised earlier and is easier to nurse, and does not suffer the disadvantage of tube pedicalisation. FIG. 3 Full-thickness cheek reconstruction with folded forehead flap and fan flap following excision of post-radiated recurrent neoplasm. The disadvantage of the method described is that there may be some residual disfigurement, especially scarring of the forehead, but with a carefully applied graft this disfigurement can be reduced to a minimum. SUMMARY A one-stage full-thickness cheek repair has been described, using a forehead flap folded on itself. The advantages and disadvantages have been indicated. The writer is indebted to the Medical Illustration Department of Wythenshawe Hospital and to the Christie Hospital and Holt Radium Institute for the clinical photographs. REFERENCES BLAIR, V. P. (I92I). Surg. Gynec. Obstet., 33, 26I. GILLIES, H. D. (I92O). " Plastic Surgery of the Face." London : Oxford University Press. GILLIES, H. D., and MILLARO, D. R. (1957). "Principles and Art of Plastic Surgery." London : Butterworth & Co. ISRAEL, J. (i887). Verh. dtsch. Ges. Chit., x6, 89.